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Q <br /> MONITORING WELL INSTALLATION REPV_r <br /> Date: 11N,, CONSTRUCTION <br /> Premise Address: ".1J�—� AI � Total Depth <br /> 11 Screen Length (fr m) (to) s <br /> Well No.: W 1 2 Filter Pack (from) (to) '7 0 � <br /> Bentonite (from) (to) I ,S� <br /> Inspector: <br /> Grout (from) (to) I <br /> Drilling rig type (4A 6/f) / <br /> Permit No. �)��('9 Auger O.D. <br /> 10 <br /> Completion - Stove pi stie b (circle one) <br /> Drilling Company: <br /> e i i1AaA1Y��i61�� casing <br /> Driller: height <br /> �_ F61 V <br /> Consultant__Imu <br /> Geologist l ��� �� -� AE&rz-GROUND <br /> TY <br /> CokVL_�MN &ZI <br /> SPECIAL PERMIT INFO. Ground Surface <br /> proof <br /> Distance to sewer line <br /> l <br /> Domestic well on site - (y/ ) ft- <br /> If yes, location and distance - �W' n- <br /> J ft. <br /> '.Y <br /> 0 <br /> C <br /> SAMPLING slatad -_ c <br /> socton — <br /> Holding Temperature = yT"'�pack <br /> Method n <br /> Screening Method <br /> Tracking Sheet <br /> 49?ft. n- <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) k Qq / <br /> Storage Location �f11���� Casing type �� <br /> Blank ft- Screen <br /> Slot size k) 0 <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Filter Pack type/size I <br /> Mix Ratios 0 5 Surge Block: - (y/ no <br /> Installation Method <br /> Quantity Installed Discussed with geologist: - �/ n) <br /> Type of method <br /> EH 29 29 <br />